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Public Health
A picture of extreme neglect !
The Directive Principles of
the Constitution enjoin
upon the State 'to direct
its policy towards
securing…. that children
are given opportunities
and facilities to develop in a healthy manner
and in conditions of freedom and dignity.'
That, unfortunately, was one of the most
neglected fields in Independent India. Some
attention has been paid towards this
problem in the past decade or so but the
efforts are much too inadequate and
haphazard. Infosys co-founder N R Narayana Murthy, speaking at a memorial lecture in Delhi recently, said, 'poor public health is the Achilles Heel of Indian economy and a recurring speed breaker in our journey to growth. Public investment in health must increase if demographic dividend is to be reaped.' He cited statistics to point out India's poor life expectancy, high child and maternal mortality, low nutrition and rising non-communicable disease burden.
burden, losing at least 6 per cent of its
GDP on premature death and
preventable illnesses. Every indicator is
grim. About 90 per cent of treatments for
childhood diarrhoea and pneumonia ---
the leading causes of death among
children in India --- are wrong and 56 out
of every 1000 kids under the age of five
died in 2012.
The CAG test checked 17 Community
Health Centres declared as
Comprehensive Emergency Obstetric and
Neonatal Care but none of these had the
required infrastructure; 25 test-checked
Primary Health Centres were found to be
non-functional or functioning only
partially because of lack of sufficient staff
and infrastructure and 101 Primary
Health Centres were functioning without
doctors. If the primary healthcare centres are strengthened, almost 85 per cent of the burden on the major institutes like All India Institute of Medical Sciences, Sanjay Gandhi Post Graduate Institute of Medical Sciences and King George's Medical University can be brought down. According to Professor K Srinath Reddy, President of the Public Health Foundation of India, 'On major health indicators, such as infant mortality, maternal mortality and child nutrition, India compares poorly with many developing countries, including several South Asian neighbours. Also, there is a surge in cardiovascular diseases, diabetes, cancers, mental illness and other chronic diseases which are killing or disabling millions of young or middle aged adults.' The recently released National Health
Accounts (NHA) 2014-15 shows that the
average government spending per citizen
per year was just Rs 1,108 against almost Rs
6,300 per Central Government employee.
According to the NHA, India's total health
expenditure in 2014-15 worked out to Rs
3,826 per person. Of this, what people had
to spend from their own pockets was Rs
2,394 (63 per cent). In 2014-15, the
government's expenditure on the National
Health Mission meant to boost the public
healthcare system was Rs 20,199 crores.
Spread it over a population of roughly 1.25
billion and you get a paltry Rs 162 per head. Compared with some other countries India has a dismal record in per capita terms adjusted for purchasing power. India's public expenditure on health is $43 a year, whereas it is $85 in Sri Lanka, $240 in China and $265 in Thailand. European nations spend 10 times and the US 20 times more. According to Insurance Regulatory and Development Authority of India (IRDA), the Government contribution to insurance stands at roughly 32 per cent, as opposed to 83.5 per cent in the UK. The high out-of-pocket expenses in India stem from the fact that 76 per cent of Indians do not have health insurance. The apathy of the government is reflected in a poor planning for healthcare. Primary health centres (PHC) in villages are supposed to screen and feed medical cases to specialist hospitals in districts and further on to State-level specialist hospitals. PHCs are not present in many villages (about one for every 20 villages), and where present are so acutely undermanned that the 'access' system is broken at the first mile. As many as 18 per cent of PHCs are entirely without doctors. This impacts not only the screening of patients but also deeply impairs prevention and early detection which is a must if costs in the whole system are to be contained.
Some figures: 30 per cent of Indians don't have access to primary healthcare facilities; about 3.9 crore Indians fall below the poverty line each year because of healthcare expenses; around 30 per cent in rural areas don't visit hospitals fearing high expenses; the healthcare needs of 47 per cent of rural India and 31 per cent of urban India are financed by loans or sale of assets; about 70 per cent of Indians spend all their income on healthcare and buying drugs. 0ut-of-pocket spending in India — 69
per cent of total health expenditure — is
among the highest in the world and much
more than in Thailand (25 per cent), China
(44 per cent) and Sri Lanka (55 per cent);
nearly 30,000 doctors, 20,000 dentists
and 45,000 nurses graduate from medical
colleges across India every year, the
doctor-to-patient ratio being six for
10,000 people, way below Australia
(1:249), the UK (5:1,665) and the US
(9:548), the global ratio being 15 doctors
for 10,000 people. Meagre budgetary allocation for health services is the major factor affecting healthcare system, particularly in the rural and suburban areas. But more than that it is the mismanagement born out of indifference of the ruling classes that is plaguing the health delivery system. According to the findings of the Comptroller and Auditor General (CAG) in his report on reproductive and child health under the National Rural Health Mission for the year ended March 2016, the picture that emerges in several States is one of inability to absorb the funds allocated, shortage of staff at Primary Health Centres (PHCs), Community Health Centres (CHCs) and district hospitals, lack of essential medicines, broken-down equipment and unfilled doctor vacancies. In the case of Uttar Pradesh, the CAG found that about 50 per cent of PHCs it audited did not have a doctor, while 13 States had significant levels of vacancies. per lakh of population. There is one government doctor for every 10,189 people, one government hospital bed for every 2,046 people and one State-run hospital for every 90,343 people. In comparison to these dismal numbers, the US has 24.5 doctors for every 10,000 people and one hospital bed for every 345 citizens. There are around 734 district hospitals across the country, which provide secondary healthcare facilities to people. In addition, there are around 300 other hospitals, such as women's hospitals at the district level. They are powerful nodes in India's healthcare network and can be revitalised to boost the health infrastructure. India needs to reform the public healthcare sector's governance and management systems The approach to service delivery has
to be a functional referral linkage and
establishing a "continuum of care"
across the spectrum from village to subhealth
centre to primary healthcare,
sub-district hospital and the district
hospitals. The challenge remains to
reform the health system and its
workforce in particular, so that
practitioners, administrators and others
have the skills, knowledge and
professional attributes to meet the
emerging healthcare needs of the
community. The healthcare facilities have grown significantly in terms of numbers and expertise of our professionals, but this has largely been in the private sector. The government's failure to deliver quality care has led to a rapid expansion of private hospitals, which today account for 93 per cent of all hospitals (up from 8 per cent in 1947), 64 per cent of all beds, and 80 per cent to 85 per cent of all doctors. But mass access continues to remain a challenge.
India's Rural Health Service concept was lauded at the International Conference on Primary Health Care, held in Alma-Ata (USSR) in September 1978. Raj Narain, Health Minister in the Janata Party Government, represented India at the conference. The Declaration adopted at the Alma-Ata conference emphasised that, among other things, primary healthcare: reflects and evolves from the economic conditions and socio A parliamentary panel report on health and family welfare released last year pointed out that in India there is just one government doctor for every 10,189 people, one government hospital bed for every 2,046 people and one State-run hospital for every 90,343 people. (Needless to say that most of these facilities are concentrated in urban areas.) With a doctor-patient population ratio worse than Vietnam, Algeria and Pakistan, the shortage of doctors is one of the biggest ailments afflicting the country's health management system, the panel noted. sociocultural
and political characterises of the
country and its communities and is based
on the application of the relevant results of
social, biomedical and health services
research and public health experience;
addresses the main health problems in the
community, providing promotive,
preventive, curative and rehabilitative
services accordingly; includes, at least,
education concerning prevailing health
problems and the methods of preventing
and controlling them; promotion of food
supply and proper nutrition; an adequate
supply of safe water and basic sanitation;
maternal and child health care, including
family planning; immunization against the
major infectious diseases; prevention and
control of locally endemic diseases;
appropriate treatment of common
diseases and injuries; and provision of
essential drugs; and relies, at local and
referral levels, on health workers, including
physicians, nurses, midwives, auxiliaries
and community workers as applicable, as
well as traditional practitioners as needed,
suitably trained socially and technically to
work as a health team; and to respond to
the expressed health needs of the
community. The author is a reputed journalist. He has been a keen crusader for a well-informed public opinion. |
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N D Sharma
